Update on the Masters and Johnson Model for Treatment of Sexual Desire Phase Disorders

Factors Contributing to Low Desire and Arousal

Masters and Johnson wrote very little about their approach to desire phase disorders. In 1986, Dr. Masters and I co-authored a paper reviewing the Institute’s conceptual approach to inhibited sexual desire. Dr. Masters wrote:

“As we mature, sexual response is a natural manifestation of attraction to a person perceived as appealing. This attraction evolves into a casual or committed relationship. Once a pair-bond is established, sexual desire is a natural way of expressing the sense of intimacy that develops within a committed relationship. Therefore, anything that enhances or inhibits relational intimacy may positively or negatively influence the individual’s levels of sexual desire. Sex is innately pleasurable – unless something mitigates that pleasure. Couples who evidence little intimacy in the living room usually will feel distant from each other in the bedroom. Therefore, persons who are bored, pressured, fatigued, angry, guilty, fearful, anxious, or suffocated in a relationship are ‘entitled’ to low levels of sexual desire.”

Thus, the Institute’s approach to treating inhibited sexual desire was similar to their treatment of sexual dysfunction. The “relationship” was the primary focus of treatment rather than the symptomology. As the couple placed themselves in social isolation and followed daily suggestions to increase closeness, connections, communication and intimacy, the roadblocks that interfered with sexual desire would become obvious. Directive forms of psychotherapy were used to “neutralize” these roadblocks, and the couple’s newfound levels of intimacy eventually elevated their sexual desire. Masters and Johnson therefore concluded that there was no such thing as an uninvolved partner and maintained their treatment focus on the relationship.

This focus on the relationship has shortcomings, however, since many roadblocks can exist to blunt sexual desire, both in the individual and the relationship. Hypogonadism, certain medications, and other physical conditions can cause a man to have generally low initiatory behavior and low arousal. But present this man with a new partner, or disinhibit him with small amounts of alcohol, and he may become very desirous or aroused. Thus, dispositional and situational factors can affect desire. Similarly, if the same man has been enmeshed with his mother, sexually abused, or developed body dysmorphia or any other injury to sexual unfolding, he may evidence disturbance of desire. The treatment of inhibited sexual desire must vary relative to its contributing factors, using different interventions to achieve successful treatment.

In addition, since individuals often choose partners who have similar or compounding issues, two people together can create a more complicated problem, often because when one person says no to sex, the other may feel unloved or rejected. The couple then manifests marital distress and conflict in other areas of their relationship. This starts a domino effect, a series of deleterious influences on levels of sexual desire in the relationship. Both partners may label the person most affected as hyposexual. The other partner feels undesirable and frequently reacts by increasing his or her demand for sexual interaction. This elevated level of sexual demand increases performance anxiety in the inhibited partner and may lead to sexual dysfunction, which further lowers desire.

More dominos fall if the individual with low desire attributes the problems to “falling out of love.” Feelings of low self-esteem, insecurity, guilt, and other negative emotions, such as depression, follow. Add a serotonin reuptake inhibitor to treat the depression and you put the “icing on the cake” for serious sexual and relationship damage.

The most frequent relational issue contributing to low sexual desire is ignorance. We consider the lack of knowledge about sex and physical intimacy a public health crisis; few people know adequate techniques for mutually pleasurable lovemaking. Instead we often see a compulsively driven, mechanical interchange focused on orgasm, ejaculation and tension release. The intimacy, connection, tenderness, and exchange of affection is limited. The widespread availability of pornography, with images of sex acts that reward size, staying power, and jackhammer-like technique, have added to the crisis, since many people “learn” about sexuality through these images. Younger generations are showing a tendency to be even more mechanical, less affectional, and less responsive to touch.

Another common couple issue influencing sexual desire is explicit and implicit contracts. For example, a traditional couple might make an implicit contract that the man will be the provider, the woman the homemaker. If either fails to hold up their end of the bargain, sexual desire can be affected. Many of these contracts are doomed from the start, since the assignment of such roles creates inherent contradictions. A partner might expect the spouse to be a successful surgeon, yet also want an engaged and equal partner to assist in raising the children. When the spouse cannot do both, the partner becomes frustrated and loses sexual desire. In other couples, if the woman earns more money than the man, the man may feel threatened and insecure and lose sexual interest.

A common factor therefore with low sexual desire is the inability to express emotions to the partner, such as hurt, frustration, or anger to solve conflict. Conflict, if handled optimally, can bring a couple closer, but rarely do the partners have the tools or training to deal with disagreements. A partner unable to feel, label, or express emotions may instead rely on sex to feel loved, placing extraordinary pressure on the other partner. For this reason, marital and relational therapies are almost always integrated into the sex therapy.

Another major factor contributing to low desire is the reduction or absence of courting behavior once married. A couple fails to give a high priority to having fun, playing or being romantic once they are ensconced in their marriage. Instead they fill their time with work obligations and childrearing. They forget or never discover how to be spontaneous and enjoy non-goal interactions. Their sexual expression mirrors their serious hard-working lifestyles and becomes mechanical or boring. Perfectionism leads to goal orientation; the harder one works at sex, the less spontaneous, playful and enjoyable it can become.

Although immediate factors contribute to maintaining low desire, as Helen Kaplan (1974) noted, “deeper” issues are frequently at the core of desire and arousal problems. Masters and Johnson focused on the “relationship,” that is, the difficulties that both the individual and the couple have in becoming bonded. Bonding disorders originate in the developing attachment systems and the cohesiveness of self-development, discussed later.

Intimacy and Intimacy Disorder

A couple often establishes a reactive distance related to dependency-independency, closeness-distance, freedom versus control, privacy versus self-disclosure, which once established, the partner often adapts to: low sexual desire is usually a sign that this distance is too little or too much and needs realignment. Often the attachment styles of each individual complement each other.

The Development of the Affectional Systems

It is valuable to view sexual desire through the lens of attachment theory because, as Dr. Masters noted, desire is often an aspect of pair bonding, courtship, attraction, love, affection, and intimacy. Sexual desire and arousal are the endpoints of a series of developmental events that begin with genetics and temperament, move through the child’s early attachment environment with caretakers, and can be disrupted by subsequent experiences that are so overwhelming the child is unable to assimilate them. This disruption can result in affect dysregulation and impaired gender-related socialization and self-development, all activated by pubertal hormones.

A person’s attachment style is established in the first two years of life and remains stable from 18 months to 20 years with about 72% consistency (Soloman and Main, 1997). The mother’s attunement to her child facilitates the experience-dependent maturation of the child’s neurological structure, which directly influences the child’s biochemical growth process, as well as dendritic and axonal developments in the first two years of life. When feedback from caretakers is absent, punishing, frustrating, invalidating or rejecting, the consequences can be written into the structure of the developing personality. Children may be emotionally constricted (Main and Soloman, 1995), turn into themselves and disconnect from others (avoidant), or emotionally dysregulated. An emotionally dysregulated child will either fail to use others for comfort or become anxious, fearful and so dependent on others for comfort that he or she refuses to separate and explore the environment.

As children age, they seek familiar, consistent environmental interaction, even if it may be damaging to the self. So they will recreate and reenact familiar early rejection and frustrations (Stroufe, 1988). Injured early attachment bonds, like those described, are highly predictive of later relational distress and create the framework for how an adult couple will interact sexually. Table II lists attachment classifications: Individuals rated anxious/ambivalent are both starving for affection and fearful of close relationships; avoidant individuals report never having been in love or having had strong experiences of love.

Individual differences on the anxiety and avoidance dimensions accurately predict differences in the way people experience romantic and sexual relationships. People who rank low on anxiety and avoidance (i.e., securely attached) tend to have long, stable, and satisfying relationships characterized by high investment, trust, and friendship (Collins & Read, 1990; Simpson 1990. In the sexual realm, they are open to sexual exploration and enjoy a variety of sexual activities, including mutual initiation of sexual activity and enjoyment of physical contact, usually in the context of a long-term relationship (Hazan, Zeifman, & Middleton, 1994). Secure adolescents engage in regular dating and establish romantic relationships. They are more likely than insecure adolescents to be involved in long-term relationships, and they report having more frequent sexual intercourse than avoidant adolescents (Tracy et al., 2003).

Avoidant adolescents, as one might predict, tend to avoid sexual relationships altogether. Tracy et al. (2003) found that avoidant adolescents were less likely than their anxious or secure peers to have had a date, sexual intercourse, or any sort of sexual experience. Avoidant virgins scored high on measures of erotophobia. Avoidant people are less likely than their counterparts to fall in love (Hatfield et al., 1989), and their love style is characterized by game playing (Shaver & Hazen, 1988). Tracy writes “attachment avoidance interferes with intimate, relaxed sexuality because sex inherently calls for physical closeness and psychological intimacy, a major source of discomfort for avoidant individuals” (2003, p. 141).

The type of insecure attachment style also helps to determine a person’s behavior in romantic and sexual relationships. Persons who rate high on the anxiety dimension and low on the avoidance dimension tend to become obsessed with their romantic partners (Hazen & Shaver, 1987) and experience low relationship satisfaction and a high breakup rate (Carnelley, Pietromonaco, & Jaffe, 1996; Collins, 1996 & Read, 1990). They are more likely than secure or avoidant people to experience passionate love (Hatfield, Brinton & Cornelius, 1989) and exhibit an obsessive, dependent style of love (Collins & Read, 1990; Feeney & Noller, 1990; Shaver & Hazen, 1988). On average, they display a stronger preference for the affectionate and intimate aspects of sexuality (hugging and cuddling) than for the genital aspects (vaginal, anal or oral intercourse; Hazen et al., 1994). Attachment anxiety is also associated with concern about one’s own sexual attractiveness and acceptability, an extension of anxious individuals’ general concern with rejection and abandonment (Hazen et al., 1994; Tracy et al., 2003).

The cost of living with an avoidant style of attachment is numbing: the absence of emotions, including compassion, plus an inability to experience the full breath of love, and the sheer beauty of the world. Avoidant persons feel a spiritual disconnection with the planet and its people. To avoid the pain of loss and grief, they must limit the capacity for pleasure and play — both essential for satisfying sex.

Development of Self

One of the remarkable findings of Sroufe and his colleagues (2009) is that children who developed a pattern of disorganized attachment, with co-existing avoidant and preoccupied strategies at 18 months, were dissociative in long-term follow-up, suggesting segregated internal models of self and the attachment figure. The individual clinically presents with a statement such as, “ I don’t know who I am,” I feel like an imposter,” or “I feel like I’m bad and pretend to be good.”

At the core of one’s capacity to bond are self-empathy and the capacity for self-care. In the absence of alternative validating caretakers, the individual does not internalize a caring relationship with self. A rejected or abandoned child tends to develop negative core schema or beliefs about self and in some cases about their gender or body.

Accompanying modes of processing and organizing information unfold such that these beliefs become self-perpetuating. These modes ultimately organize an individual’s range or type of interactions, which constrains possibilities of new learning with respect to intimacy.

The self comes to exist primarily in the context of others, within an aggregate of experiences of “self-in relationships.” Invariant aspects of self and others are abstracted into what Bowlby called “internal working models.” New experiences are then absorbed into earlier representations, creating and maintaining and repeating core schema. The internal working models of individuals with disorders of intimacy may be filled with self-hatred, so the person compensates by being powerful, controlling, dominating or alternatively feeling inadequate and weak.

The effect on sexual desire is that sex is used as a performance to feel adequate, desirable, and attractive and to “keep the partner satisfied” rather than for mutual satisfaction. They experience “otherization,” being overly focused on others at the expense of self. Sex as a performance creates enormous pressure to perform well, which can eventually degrade performance and desire. The result is the same type of numbing noted in the earlier descriptions of avoidant adolescents.

During the second or third year of life, tolerance for separation and the capacity for self- soothing is organized. Having a “secure base,” allows for exploration and the capacity to master and solve problems, thereby feeling effective, competent and powerful. The secure child begins to internalize the belief in “being valued and loved,” and does not need constant reassurance.

Individuals with attachment injury do not form this secure base and need the constant mirroring of others to maintain their sense of self. They can become suggestible and susceptible to influence. They become human “doings,” perfectionists always trying to not disappoint others, feeling only as good as their last accomplishment. They tend to have difficulty with creative problem-solving, constant worry and feeling powerless. Often they suppress affect, becoming mechanical and instrumental. In their attempt to gain affection, they need to conquer the partner who is rejecting them. Once they conquer, their sexual arousal diminishes and their sexual goal is for physical release rather than true affection. Intimacy terrifies them due to to fears that the closeness makes them vulnerable to abandonment. To protect themselves, they create distance by losing interest in the partner, and using pornography, affairs, or other distractions to stay busy and tired.

The attachment system evolved as a biological alarm. It ensures the survival of the species by detecting potential harm and signaling terror to stimulate action. If the caretaker moves away, disrupting the secure base, and the individual has an internalized working model to create a secure base, the attachment system will be activated and the natural result will be terror. The child will seek the caretaker or cry for attention.

For the preoccupied individual who lacks a secure base, people wanting to have sex with him or her is reassurance of desirability and reduces fears of abandonment. In avoidant attachment, getting close activates fears of danger or annihilation, since the people a child once depended on were dangerous or neglectful. In disorganized attachment, both systems alternate, thus needing sex and needing distance simultaneously. Many symptoms of relational distress as well as psychiatric symptoms can be better understood when seen through the lens of attachment activation. Helping the individual form internal and external safety zones can neutralize fears related to closeness and distance and reverse sexual desire issues.

Most critical for developing a secure base are self-core schemas of safety, trust, esteem, power, control, and intimacy. The development of these core schemas is altered when early events engrave negative beliefs into the developing brain — i.e. “I feel fat. I am stupid. I am bad.” — although the thoughts are irrational and without evidence. Such self-hatred requires the person to perceive others consistent with these beliefs, thereby setting up biased filters. So if the partner is perceived as smart, beautiful and thin, the signal of fear is activated, increasing a preoccupied person’s desire for reassurance, or an avoidant person’s loss of interest.

Love Maps

Another critical component of the developing affectional systems is what John Money (1981) defines as a “Love Map: a personalized developmental representation or template in the mind that depicts the idealized lover and the idealized program of sexual erotic activity with the lover as projected in imagery and idealization or actually engaged in with the lover.”

Money believed that actual biographical events related to attachment and trauma influenced the development of love maps, and that they can be “vandalized.” Too much punishment associated with the unfolding of genital sexuality or premature sexualization in the family can interfere with sexual arousal development. (See also the book Sexualized Children by Eliana Gil and Toni Cavanagh Johnson.)

The developing love map includes partner characteristics that sexually arouse the body to respond to touch, and the sense of self as attractive, which indirectly influences the perception of another as desirable. The love map is hard-wired to respond to a variety of emotions such as illicitness, conquest, fear, intimacy, romantic love, and challenge. Early themes such as taking care of others or caretakers being out of control, hostile or abusive become templates for “falling in love.” The way one is loved as an infant can become a “blueprint” for adult affectional style. Puberty then activates the love map that was established throughout childhood.

The fantasy or imagery a person uses to arouse him or herself in masturbation can then organize the choice of partner, affectional interchange, and sexual desire and arousal. If the adolescent uses pornography, these images then serve to over-learn certain arousal patterns; some individuals use it as a form of disengagement. For these individuals, more and more stimulation seems to become necessary to reach orgasm. Tolerance to stimulation increases, probably because of a kindling effect on the central nervous system. Sexual arousal becomes channeled toward the computer screen rather than through the natural channels of touch, closeness, and affection.

If a man develops avoidant attachment, for example, he might become fixated on the woman’s breasts and become aroused by the image of the breasts rather than the woman, a strategy that allows him to maintain a distance from the person. Another man might require the image of his “secretary” or a scene from pornography to maintain distance and not become too intimate. Eventually, the imagery alone satiates, undermining any sexual interaction with the partner. For preoccupied individuals, sexual activity can become a means of reassurance that their partner desires them, and sex then becomes obsessive, mechanical, and obligatory, often reversing the partner’s desire for sex.

Treatment Implications

Mate selection, as driven by attachment theory, would often find the avoidant person pairing with a partner with preoccupied attachment. This coupling establishes a merger-seeker relationship in which the sex drive is high for the merger and low for the seeker. The couple presents with the seeker labeled as having low sexual desire, with subsequent damaging domino effects to the relationship, when the actual problem is their complimentary attachment patterns. If either had chosen a partner with secure attachment, he or she might have avoided sexual difficulties. The focus of therapeutic intervention in these cases would be on individual and couple issues as well as what Helen Kaplan (19__ ) called “deeper issues.”

Our work on deeper issues has focused on shorter-term interventions to move individuals towards what Mary Main defined as “Earned Secure Attachment,” which refers to repairing insecure attachment (Schwartz 2017). Table 2 lists the components of our work to develop Earned Secure Attachment, derived from Main’s Adult Attachment Interview Assessment. The treatment consists of helping the individual revisit their memory of sequential developmental experiences and (as summarized by Brown & Elliot, 2016) “become more aware of his or her immediate mental state, learning to accurately mark, label, and understand affective states and cognitive status, such as maladaptive beliefs and schemas, becoming sensitized to the limitations of knowledge and beliefs, learning to identify states of mind, and becoming able to mentalize about others’ state of mind and about the transference in their therapy.”

The ultimate aim is a reappraisal of their life experiences and reconsideration of their fixed beliefs and conclusions about self, others, and their capacities to master and resolve problems. Core schema related to trust, safety, power, control, and intimacy are reconsidered and become more rationally based in their adult world as opposed to frozen, fixed beliefs based on past traumas or adverse developmental events. At the core of one’s capacity to bond are self-empathy, the capacity to be alone, and self-care.

In the absence of validating caretakers, the developmentally disturbed individual does not internalize a caring relationship with self. A child who is rejected or abandoned may develop negative core schemas or beliefs about self, which organize ways of relating to others. Sroufe (2016) reports that a history of maltreatment as a child, in a longitudinal follow-up of 170 children from birth of adulthood, “almost never has a positive outcome.” The individual attempts to create safety and consistency in maladaptive ways, such as finding others who need taking care of, to create an illusion of safety and control. Sroufe also found that the long-term result of early disorganized attachment patterns left individuals vulnerable to fragmentation of the self — dissociation. Such fragmentation leads to the proverbial “addictive personality,” or internally felt emptiness in which the individual never quite feels connected or safe.

Thus, the critical feature of recovery is learning to use other people as a reliable source of comfort and safety. To do this, we integrate trauma-resolution therapies and grief work into the process, with a focus on challenging family loyalties, fixed beliefs, or shame-based family rules. As the client experiences greater self-compassion and resolves past “unfinished business,” they are less likely to project their internal conflicts onto their partner and use sex to feel safe and connected. Repairing vandalized love maps requires revisiting the critical experience and reactivating the affect in the safety and containment of the therapist’s office, allowing for reconstruction of core schema. Our experience is that fantasy and sexual arousal patterns shift as the client uses others for secure attachment, and becomes channeled toward touch, closeness, and affection.

Summary

Repairing sexual desire is complex and requires a focus on deeper capacities for intimacy and connection to self and others, as well as choice of partner and subsequent relational dynamics. All of this is further influenced by biochemistry, drug use, factors shaping the CNS structure during critical periods of sexual unfolding, and the mind’s development of love maps. Therapeutic intervention is now more targeted and effective, as the conceptual model has shifted from sex to love. The ultimate goal of successful therapy and healthy sexual functioning is to strengthen the individual’s capacity to be fully present and available in a safe and trusting relationship.